Okay, Lean Practitioners and LSSBBs, what is the root cause of too many simple, basic mistakes. The parts we make are costly and fragile. So, we use an IATF-16949 quality management system. We’ve got training documents and training matrices. We’ve got supervisors doing job observations and layered audits. Still, people make a lot of fundamental mistakes like:

* Mixing the wrong chemicals * Not calling maintenance when things are only semi-broken * Turning pumps on when hoses are not connected * Putting 8 parts in a box clearly made to hold 9 parts, even * Bypassing Poke-Yoke fail safes

We are doing lots of things right, but clearly we are doing something fundamentally wrong. I suspect it has something to do with not being disciplined about following work instructions, and/or not enough oversight by managers and supervisors.

The things you have listed give the impression that management is not walking the talk – everything in your list are the sorts of things one sees when quality is just an empty slogan and the only real focus is on timed throughput.

Have you actually sat down with each of the subsections of your process and built a real fishbone diagram that shows what is really happening? My experience has been that when issues like yours arise a good fishbone will show exactly why they are occurring. The cause of the problems will most likely have very little to do with the people actually doing the work and almost everything to do with the environment in which they are working.

Yes, thank you Robert Butler. We have done lots of fish bone diagrams for various CI projects, but I don’t think we have honestly done our due diligence on fixing the basics problems like “Why aren’t hoses connected every time?” These issues are so big that a fish bone, 5Y and Go-and-See are clearly called for.

Chris, I like your idea of checking and see if the basic processes are in control. We can certainly do specific job observations and put a number on how well people are following established procedures. I agree that getting machine operators more involved in maintaining their machines should help prevent breakdowns. More Autonomous Maintenance is on the list for this year.

Have you seriously done gemba to understand what’s really happening, in a non-threatening way? I’ve often seen when procedures exist people do otherwise, not because they aren’t trained or they’re careless but because the procedures fit an idealized environment that doesn’t actually exist.

Strayer and Chris–I tasted, er, I mean TESTED the floor today, and it was still working well. :-)

Actually, you are both correct. We have not done a good job at teaching folks how to write good work instructions, so, the are routinely ignored because they have accuracy issues, so then you have a program that isn’t a program. Without standards, there can be no improvement! So, maybe this comes back to not-great training and so, not-great discipline, and so lots of variation in methods.

Mmmm. So, then I need to test better training and better supervision and see if improving training (mostly the work instructions and how we present them) and supervision (I’m thinking job observations or informal audits), actually improves the results. If so, then I can share our New Method.

I work with some industries that show similar problems like you pointed. What We have been doing when we cannot get the problem narrowed is take a step back and using tools from Data Science like Cluster Analysis to try come up with problem or sintoms patterns and after that, go on with the analysis.

In that case if you look at the problems as isolated facts you may not be able to identify its relationships but when you identify clues about them, find the root cause becomes easier.

I work in commercial roofing and see the same issue. The installers (and even office staff) know what to do and how to do it, but don’t always do things they way they have been trained and agree is best. I’m frustrated. I don’t know if they just DGAF, if they lack pride or incentive, and/or if there is a lack of accountability.

This is my first experience where I physically cannot control the environment (machines, software, accountability, etc.) and eliminate the opportunity to do things against procedure. You’re not alone in this search!

I have found that getting Management “In the Game” will increase the odds in your favor. To directly answer, “… clearly we are doing something fundamentally wrong. I suspect it has something to do with not being disciplined about following work instructions, and/or not enough oversight by managers and supervisors.” It might be a case of defining who ‘we” is, and the cause & effect of the lack of oversight. I think you’re seeing the effect. Maybe get a copy of “The Work of Management”, by Jim Lancaster, [ https://www.amazon.com/Work-Management-Daily-Sustainable-Improvement/dp/1934109029/ref=sr_1_2?ie=UTF8&qid=1520861366&sr=8-2&keywords=work+of+management ], sorry about the ginormous hyperlink. Get your management folks to read it, then get them to DO it. If they care about what is happening in Gemba, they will start showing up there on a predictable basis (read: daily scheduled Mgt Walk About Reviews), asking tough (but fair) questions, and providing the level of help only they can deliver.

Combine with Training Within Industries (TWI) methods, to address things from both sides of the spectrum. [1] If your management does ‘Management by Magic Wand’ (they wave their hand and The Magic Happens), you’ll forever be frustrated. [2] If employees don’t have good training (using Standard Work) they’ll find ways that work for them, but not always the best for the company, like the results you’re experiencing now. Hope this helps a little. Regards, RB

The hard but powerful way to address some problems you mentioned might be proper process description (e.g. with SIPOC) and using FMEA for it. Team effort to assess the risks and discussion of all aspects (potential failures, root cause analysis and all detection and prevention controls) might be better than any training. Having FMEA as book of knowledge may help to prioritize focus areas for continuous improvement.

Your suggestion @ssobolev may be right on point. When work instructions aren’t followed it’s often because they’re idealized rather than practical, not due to poor training or carelessness. This can happen even if people who actually do the work are involved in writing them. An FMEA exercise, if done right, can get everyone to understand what isn’t working right, and why, and lead to practical process improvement.